QUESTIONS FOR FOR SHAHEEN DEWJI, DONALD P. FRUSH, MATTHEW P. MOELLER, AND STEPHEN V. MUSOLINO
As a millennial, what attracted you to health physics? How do you think we can attract other millennials and those in Generation Z? Unfortunately, most Generation Y, the millennials, and Generation Z’s don’t know anything about radiation protection. How do we publicize this area of work? How do we make sure there are jobs for those who are interested?
S. Dewji: There has been much discussion regarding where to best target STEM (science, technology, engineering, and mathematics) recruitment efforts. I believe that STEM (including health physics) recruitment should occur at all stages of education and human capital pipelines. I was attracted to physics after initially having minimal interest to pursue studies in physical sciences, with little conception of the breadth of disciplines. It was a series of university internships that attracted me to nuclear engineering and health physics. After initial exposure to the field, reinforcing retention activities (outreach, mentorship, internships) are necessary to keep recruits engaged in the field. I must emphasize the importance of the internships; notably, of mentorship. Outreach to young people and people in early careers, mid-careers, etc., will attract interest at all levels. I strongly encourage everyone become engaged in this process, to become ambassadors of health physics. If you have someone in your community that you could mentor, you are more likely, based on that interaction, to attract and retain them in the field.
When trying to capture knowledge, how much depends on the cooperation of the individual who is the experienced one? Do you find that some people readily share information while others are more reticent?
S. Dewji: Cooperation plays a huge role in trying to capture knowledge, especially for those with the critical knowledge. Ultimately, it depends on how a knowledge management effort is socialized by the organization and if all stakeholders perceive the value of such an effort (i.e., it is not a means to capture the senior person’s knowledge in order to extricate them from their positions). It is the cultural socialization by which an institution communicates the benefit; a subject matter expert will not be accessible indefinitely and communicating that the organization stakeholders value this expert’s knowledge will emphasize that the continuity of this knowledge benefits the organization and broader scientific community.
Can you see knowledge management also used as an effective recruitment tool?
S. Dewji: The field of health physics is very comprehensive. In a field with a breadth of stakeholders (e.g., nuclear power facilities, medical facilities, federal government), identifying the core capabilities that must be retained will translate along the human capital pipeline. We must first identify which key areas require the retention of expertise; these areas must be communicated at all levels of the human capital pipeline. Adopting this knowledge management paradigm in human capital development can thus be used as an effective recruitment tool.
You stated a goal is to not bring retirees back from retirement. Why wouldn’t the ability to bring back retirees, perhaps part-time, be a goal? Why waste this human capital?
S. Dewji: The goal is not to preclude retirees from coming back from retirement. I believe that we should not become complacent with this practice. If an appropriate knowledge management paradigm is adopted, then retirees should certainly be included. Harnessing the expertise post-retirement is certainly a welcome resource. However, I would not want to see this become an ex-post-facto knowledge management approach. Knowledge management should begin as soon as a person enters the human capital pipeline.
Is nuclear knowledge management any different from knowledge management in other specialized fields? If so, what is more challenging or maybe easier?
S. Dewji: Similar to other highly technical industries, the nuclear industry has been knowledge-based since its inception. It consequently relies heavily on the accumulation of relevant “nuclear knowledge” over decades of research and development of nuclear technologies for power and non-power applications. Our current generation is the custodian of that body of accrued nuclear knowledge. Much of this knowledge will be required for future use, whether for maintenance of current activities or for future innovation. Unfortunately, the present status of nuclear knowledge and its management is still in an unsatisfactory condition, which may compromise the continued safe and secure use of nuclear technology.
The human capital and knowledge loss crisis may ever be more critical among nuclear weaponers and those who know and study nuclear weapons’ effects. Is there a parallel effort to preserve and maintain this knowledge? If so, who or where is this being done?
S. Dewji: Many programs, both domestic and international, have committed nuclear knowledge or human capital programs (beyond the scope of weapons programs). Such examples include the U.S. Department of Energy Nuclear Criticality Safety Program (http://ncsc.llnl.gov), the National Nuclear Security Administration Next Generation Safeguards Initiative (https://nnsa.energy.gov/mediaroom/factsheets/nextgenerationsafeguards), and the International Atomic Energy Agency (https://www.iaea.org/nuclearenergy/nuclearknowledge).
Donald P. Frush
Is dose monitoring being considered for part of the electronic medical record?
D. Frush: It partly depends on what you consider electronic medical record. The requirements for practices for institutions now, at least for CT (computed tomography) and nuclear medicine, are to have the dose metrics in a “retrievable format.” For some people, that might be the picture archiving system, or it might be an individual server; it may go to the extent of being actually put on the patient’s report. That will vary depending on the practice, but it’s no longer acceptable to not be able to recover this individual information for a patient. It will be on a medical record depending on how you define that, but it really is somewhat variable in terms of how practices will meet that obligation. So the answer is yes.
How will a good dose monitoring program include x rays not taken in the hospital? For instance, cone beam CT exams for dentistry/orthodontistry? Other than asking parents to do this tracking of dose, is there a role for insurance companies?
D. Frush: Current requirements for dose monitoring through the Joint Commission [TJC] for nuclear imaging and CT apply to accredited hospitals, critical access hospitals and ambulatory health care organizations. I assume there are other accredited and non-accredited facilities that would not be under obligation to meet these standards. In California, the requirement to have dose metrics in patient reports is for CT and nuclear imaging. To the best of my knowledge, there is no similar program for computed radiography and direct radiography on a national front. The state of North Carolina does require adherence to technique charts that comply with standard ranges based on the National Evaluation of X-ray Trends, and I am sure this will vary state-to-state, but this does not require an individual patient dose metric monitoring as is now required for TJC accreditation. Notably, the TJC revised guidelines for CT do not apply to cone beam CT. The NCRP report on dental imaging that is, I believe, near final (one author is Alan Lurie) addresses variability and discusses DRLs (diagnostic reference levels) in dental imaging.
I don’t know what “role for insurance companies” means. If this is meant to imply that a clinic won’t get reimbursed unless they have dose monitoring, to my knowledge this doesn’t exist. I don’t think that they can or could develop their own monitoring program. I am distrustful of third party payers hinging reimbursement on aspects of medical care that are still not well defined (e.g., what is inappropriate dose or an incomplete dose monitoring program).
Radiology residents do not receive a message of urgency regarding the need for a thorough understanding of radiation and its potential to cause adverse effects. How can attending radiologists change this situation?
D. Frush: This is requisite knowledge for residency training and includes radiation biology and medical physics. Board certification process both through the core examination as a third year resident as well as the certification examination contain such content. What is sufficient will always be called to question. Anecdotally, as an oral board examiner for years, I clearly saw an evolution from more unbridled use of CT and lack of awareness of potential radiation risks to a much more facile discussion of these elements in the final years before the oral format was sun-setted (the last full examination was in June of 2013). There is ample content available online and meeting options for those training programs that do not feel they have effective resources to teach this competency.
We are pretty good at estimating adverse effects from ionizing radiation exposure. Do we need to get better at articulating the benefit of getting that x-ray or CT exam? Are there resources to develop this and quantify this?
D. Frush: The answer is yes. That was one of the main parts as we’re so inundated with risk and defense of what we do, that we’ve not been good about getting the message out for the benefit of CT scan. I would argue how do you get that message out is a question that I asked at our dinner two nights ago. How do you do that? The media doesn’t want an article that says, “CT examinations are extremely valuable, they save lives, physicians are interested in doing things that are right and are willing to have discussions with you about the benefits of these examinations.” No one wants to read that article. They want to know that CT examinations are actually harmful. No one wants to read an article that the police force is behaving responsibly; they want to read an article that says there are drugs missing from a raid or that they’re beating people up. No one wants to read an article that says college football coaches are actually decent human beings and treating their players fairly; they want to read stuff about abuse. That’s what sells, that’s what the media is all about. I don’t have good things, other than we try to stay on message about the benefits of CT examinations. We need to try to do that, we need to work through the Image Gently®, Image Wisely®, and we need communication experts. I would argue that we haven’t been very good through advocacy groups at getting this message across, nor on social media. It’s how the public functions now. Those are areas that I think we need to go into. We’re on the defense a lot.
Matthew P. Moeller
You suggested that we take the other guy’s job and this one says, how does this compare with what industrial hygienists (IH) are doing and is the number of IH jobs shrinking?
M. Moeller: That’s a very good question. As you may know, Dade Moeller has a fair number of industrial hygienists also, and that part of our business is growing. We see a more specific need on the Hanford site to monitor during D&D (decontamination and decommissioning) operations for potentially hazardous airborne materials, not just radioactive materials. I would suggest that industrial hygiene is actually an expanding profession as opposed to a shrinking one.
What was HP role in the Deepwater Horizon oil spill?
M. Moeller: Our response to the Deepwater Horizon oil spill was not one of a health physics role. Our efforts were specific to sampling, characterizing the ecological damage, and maintaining proper chain of custody of sampled materials. The connection to our health physics services was that we were able to bring proven practices from our other work to this environmental sampling and quality assurance job.
Beyond SMRs (small modular reactors) powering desalination plants (which I favor), we’re (University of California) being pressed to be carbon neutral. What better way than to put a 10 MW SMR on every campus?
M. Moeller: I agree. That said, it is apparent that the current energy policy in the United States is to only use nuclear power as a bridge until non-nuclear carbon-neutral renewable energy sources are available. It is also apparent that the nuclear bridge will not grow beyond the existing number of nuclear power plants. Consequently, it is not likely that an SMR will be put on a university campus.
Do you think the role of a health physicist needs to evolve to fit what appears to be shifting needs? What do you envision this looking like?
M. Moeller: This is the key point in my message. The role of the health physicist must change and it must change to meet the economics of work to be performed. Today’s reality is that generalists are conducting health physics activities and filling the majority of radiation protection jobs. Furthermore, health physics programs have been developed and implemented for virtually every type of operation. With established programs, individuals with lesser education, qualifications, and experience are filling the jobs to conduct programs. When operations remain routine, the programs are adequate and executed at lower cost. One approach to filling jobs with health physicists is to improve their cross-training to cover the broader areas of industrial hygiene and occupational safety. In effect, it is flipping the generalist approach. Rather than fighting the economics of a generalist of lesser qualifications filling a health physics job, change the economics by moving up and taking jobs covering more safety functions with greater health and safety responsibilities.
You offered the very proactive suggestion that a new mission is needed for nuclear technology—to solve the world’s water crisis. There are a number of world problems that could be addressed, but do you think that society/culture will support such a mission or do you think that the fear of radiation will stop such an initiative in the early stages?
M. Moeller: This is a terrific question that targets the reality of how “nuclear” and “radiation” are perceived by members of the general public. I believe that these negative perceptions may be overcome when the benefits overwhelm the fears. Because of a lack of clean water, waterborne diseases are killing people. Hopefully preventing actual deaths will become the most important topic in the discussion. An abstract that I prepared on this issue is as follows.
The stigmas of “nuclear” and “radiation” are adversely impacting important humanitarian initiatives. Clean water is the most basic necessity promoting human health and welfare. It is essential to improving living conditions, reducing the prevalence of waterborne diseases, and increasing agriculture and livestock yields. Globally, 6.8 billion people rely on the 0.007% of Earth’s water that is freshwater. Sadly, 783 million people worldwide, representing one in nine, do not have access to clean water, and one death in five children under 5-y old is due to water-related diseases. Disadvantaged populations will never overcome health disparities or achieve health equity without access to sustainable quantities of clean water. While desalination of saline or ocean-based water is advancing worldwide with large-scale plants, such projects are not realistic in poor countries because of the high energy and infrastructure costs. The economics of desalination could be improved by using a self-contained power source and limiting the infrastructure to local water distribution. The technology exists to co-locate a small nuclear reactor generating electrical power with a scalable desalination plant to provide clean water. Today’s small modular reactor designs have inherently safe features and inaccessible fuel making them proliferation-proof, and they can provide continuous power for decades. While coupling these small-scale plants is a local solution addressing a global problem, the option is shunned. Educating decision-makers is one part of the solution. Our profession doing a better job of promoting good science is another. Perhaps there is common ground given the need for clean water.
Based upon HP operations being routine and being performed by generalist, how does this compare with industrial hygienists? Are those jobs shrinking?
M. Moeller: Perhaps the number of jobs is going down for HPs; however, they are going up for RSOs (people who do not call themselves HPs).
Stephen V. Musolino
How much activity of a source would be needed for an RDD (radiological dispersal device) to make a significant impact radiologically?
S. Musolino: I prefer not to discuss anything that concerns device design.
Then I’ll give you another one. What is the status of the ROSS (Radiological Operations Support Specialist) concept? Old timers will likely need some level of training for some concepts. Is this training considered?
S. Musolino: The answer to your question is yes. I’m not the best expert on ROSS. I’m peripherally involved with it so far. The intent of the program is to provide training that includes working within the incident command structure on how emergency response is planned for and carried out on a national level, and specifically on the DOE (U.S. Department of Energy) capabilities to support consequence management with assessments for decision makers, as well as working as a member of a team effort. Anyone who is not familiar with all that would become familiar with it through the training program.
There is solid evidence that any indication of radiation involvement will dramatically decrease EMT [emergency medical technician] response and lead to hospitals refusing admissions. How does this affect the science, especially when you add in public panic; even the feds understand there will be a 3 d window before an organized response will be raised?
S. Musolino: The point you raise is precisely one of the endpoints we’re trying to address by reaching out to the cities and encouraging them to actually write a tactical RDD plan for the first 100 min. Doing so will lead to addressing that problem. If the first responders like the EMTs don’t have knowledge about radiation and understand that they can perform their job successfully and minimize their risk, then precisely what you describe would occur. We as a nation have to face this problem, and I personally hope that this project does gather momentum. We expect it to after we get the first four cities done. The product will be turned over to FEMA (Federal Emergency Management Agency), and hopefully there will be many more me-too’s and more cities throughout the nation who want to go with this planning and that will help alleviate the problem. Just in terms of the 3 d window, that’s sort of the nominal timeframe where the full federal response will be in effect; but certainly for a radiological incident, the DOE emergency response functions will be deployed in a phased manner. Some will happen in the first few hours, some will happen in the first day, and certainly the radiological support to the local agencies will happen in much less time than 3 d in terms of the emergency phase support.
Your timeline is based on a single device. Isn’t it more likely that there would be multiple devices and how would that change your action timeline?
S. Musolino: Regardless if there is a secondary device or not, the timeline is going to be a reflection of the resources available to a city as well and the degree of preparation. If a second device were part of the scenario, all the principles of the response would be the same but possibly carried in two places. Also note the 100 min timeline is notional and adjustable to the resource constraints and local conditions.
Please comment on nonexplosive radiological dispersal scenarios. Why are these omitted?
S. Musolino: If I make a comparison between one and the other, it crosses over into device design. I prefer not to discuss anything that concerns device design.
Do the ballistic particles have enough velocity to cause shrapnel wounds? Technical question.
S. Musolino: Yes, embedded ballistic fragments could occur, especially from radioactivity in metallic form such as cobalt. There is a related paper on medical management of a victim who might need to have fragments surgically removed (Smith JM, Ansari A, Harper FT. Hospital management of mass radiological casualties: reassessing exposures from contaminated victims of an exploded radiological dispersal device. Health Phys 89:513–520; 2005).
To be effective and credible, ROSS must exercise regularly with their counterparts. What provisions are being put in place to ensure that ROSS members are trained and treated as “ordinary” members of the response team?
S. Musolino: There is a formal training program in the process of development that will address three levels of expertise with the expectation that ROSS will integrate within the incident command structure. For example, in the field with an incident commander, in the planning section, etc. Participation in exercises is another means to integrate ROSS. In that regard, the ROSS role has been played at the last two vibrant response IND (improvised nuclear device) exercises sponsored by FEMA.
How do we introduce a more rational approach to evacuation and other actions? From a risk standpoint, the future risk of a dose at 10 mSv is less than the evacuation risk.
S. Musolino: I agree that risk-based evacuation decisions are the right approach. It is well known from large disasters like Katrina and Fukushima that evacuation-related fatalities occur when large numbers of people are displaced, especially in sensitive subgroups like the elderly or persons with serious medical conditions, compared to the small additional risk from a dose in the range of 10 mSv. I do not have a solution on how to get to this approach, but it is the scientifically correct means.
What are your thoughts on ways to bring younger colleagues who want to be involved into groups for emergency response and for security, professional societies, etc.? What kinds of outreach can be done so they can gain the experience we want them to gain?
S. Dewji: I think that young people are very energized right now. They want to be involved, and they want to make an impact in their community. I think if you reach out, you’ll get a lot of positive response. I think just making that overture and giving them some action items, some follow through, some reinforcement, I think that they are very motivated to contribute back to the security and safety of their communities.
M. Moeller: I also think we need to get people out in the field whether it’s internships at the very earliest level or just job shadowing or creating opportunities. I referenced in my talk the notion of office HPs (health physicists). I think it’s an incredibly important field experience to have held the meter, to use the meter, to understand that in pressure situations when the unexpected happens, the brain works a little bit differently. It’s a lot harder to keep calm and collected in very challenging, stressful environments. Having field experience where you kind of kick the tires and have been around others and have the confidence to know how to use very specialized equipment that would be applicable during emergencies, I think is essential.
We’ve all agreed that we may need more people to fill the pipeline. What are some ways you’d recommend to get more people interested in these radiation protection fields? Do students even know these are options? How do we publicize this area of work? How do we make sure there are jobs for those interested?
D. Frush: I don’t think this applies as much to medical imaging as the other professions. There is a much greater partnership now between medical and other professions who use/regulate, and this engagement will need to continue so that the expertise can flow easily and efficiently. The specifics of training for medical practitioners with respect to delivery and responsibility for ionizing radiation will continue: from above, “From the radiology standpoint, radiation biology and radiation protection have always been obligatory parts of the resident training, but 20 y ago it was note cards and formulas on the way to the examination trying to remember the medical physics; and with restructuring of Board examinations and input by the medical physicist communities into better educational content, it is a far superior examination process that is much more image-based and practical for the trainees now. We have yet to see how that rolls out over the next few years, but the last 5–10 y, I think, have been a substantial improvement in the training and understanding of radiologist’s role at the early level.”